Hotscot

Sorry to hear Geoff...I agree very much, it's such a mess at times.
This morning, took wife for a steroid shot for sciatica to a clinic after she was referred by her Doc who's covered by Anthem Blue Cross.

That'll be $600 thank you.
What??

Yes the clinic itself doesn't have an agreement with Anthem Blue Cross.

I offered them $500 which they took.

GeoffM

$500, ouch. Yet to have massive bills but I won't be at all surprised if they start arriving, covered or not.

Though a certain autism provider did bill Kaiser Permanente for a couple of grand for 2 months after we moved and stopped using their services. The weird thing is KP actually paid them even though - when I talked to their claims department - they said it was obvious we weren't members at the time and thus weren't authorised for such services. The last thing I wanted was for KP to pass the bill to us instead!

Regarding DD, there's nothing that can be done anyway, just a monitoring exercise really, so I think we'll just leave it until the new year when we can hopefully get somebody more local with a better health plan. Damned if I'm going to spend yet another best part of a whole day sitting in a bloody doctor's surgery filling in umpteen forms yet again just for the doc to say she's ok when I'm 99% sure she is anyway.

Just in case anybody thinks I'm withholding/delaying treatment for DD, of course I would not do that. It's a growth defect and is untreatable.

petitefrancaise

Our health insurance has been really great so far.....BUT from January we will have to go in-network unless we opt for the in and out of network plan which will be more than we are paying now for it. One problem that I foresee is when my eldest heads off to college elsewhere and she will have to locate an in-network provider. HR dept have strongly advised those of us in this situation to opt for the in+out of network coverage. Anyone else had to deal with this? How are the kids at managing this? Thanks

Michael

Be very careful with plans that only allow in-network providers. Those are normally EPO plans and until recently, very few employers offered EPO plans since they can be a very big headache for non routine services (just ask Geoff).

You may pay more for an in-out of network plan but with an in-network only plan, if something serious happened to you or someone in the family and were taken to a hospital that was out of network, you could have medical bills in excess of $250,000 but with in/out network plans, out of pocket expenses are normally capped for both in and out of network treatment,

petitefrancaise

Emergencies are covered no matter where we go. It's the routine stuff we will have to go in-network for. I'm not worried about how we would get on here in Austin, I am more concerned with the fact that my eldest will be away. Unfortunately, we have to decide which coverage to take before we know where she will be studying, so it's not easy to check in network docs for her. I miss the NHS...and the french secu sometimes!

MarylandNed

Yes, you have to be very careful about any healthcare provider you go to. If in-network provider A refers you to provider B, that doesn't necessarily mean that that provider B is in-network. You have to specifically ask. If in doubt, check with your health insurance company.

Another common gotcha is when you call a provider and ask if they "accept" your health insurance plan. An answer of "yes" doesn't mean that they are in-network. They could be out of network but just happen to accept your health insurance plan for billing purposes. Specifically check if in-network or out of network.

Hotscot

Well that was $500 well spent.
After a month in agony my wife has no pain. Of course the steroid has simply reduced inflammation of the nerve but now her herniated disc can heal with time, and she can do back strengthening exercises.

petitefrancaise

Well, I'm ready to scream.......
I fell over whilst running in June and hurt, amongst other bits, my shoulder. I saw 2 family doctors, 1 orthopedic doctor and I've had 2 xrays taken. They've prescribed high dose ibuprofen, steroid tablets (sent me a bit crazy!) and a steroid shot straight into my shoulder as it continued to hurt me. I then went to see a chiropractor for re-hab deep tissue massage as they all seemed to be telling me that it was inflamed and that was why it was still painful. Finally, after 4 months Iget an MRI done to find that there is a deep tear in there that was never going to improve without surgery. When I ask why they didn't do an MRI in the first place the response was that the insurance company make the doctors do re-hab first and if that doesn't work they will pay for an mri.....AGHHHHH!!!!!

Michael

EPOs have too many rules and are cheaper because of the rules. PPOs don't have such rules since no referrals are required.

petitefrancaise

This is a PPO policy at present.it's due to change in January.
I can't self refer for MRI and it must be authorised in advance.

Michael

I agree that you can't refer yourself to a MRI but I've never heard of a PPO having regulations that required the doctor to go through certain procedures if his/her best judgment is a different procedure. Usually for a PPO, the doctor just has to call the insurance company to make sure that the procedure is covered and not call the insurance company as to how to treat you.

petitefrancaise

My son's had to be pre-authorised too. They're not telling the doctor how to treat you, they're telling you what they will pay for. BUT it's much the same thing isn't it? If my doctor had said that he thought I should have an MRI back in June but my insurance had said we'll pay for it once you've tried xyz, then I'd probably have waited rather than fork out for the MRI. The doctor also said that in 80% of cases like mine, re-hab is what is needed, unfortunately I was the 20%. I'm still mad about taking all those pills and 4 months of lack of sleep though.

Michael

It isn't the same. When I've always looked at my PPO policy, it indicated that I am covered at a certain percentage for in network treatment and a different percentage for out of network treatment and not only if you went through other procedures first. The problem prior to ACA was that not all insurance companies covered the same procedures and some companies didn't cover certain procedures in states that didn't mandate coverage for those procedures. That was why doctors had to get approval since they couldn't figure out which procedures were covered. For ACA complainant policies, all policies cover the same procedures.

The big difference between PPOs and EPOs or HMOs is the requirement of referrals. Once referrals are required, the insurance company now has control over when procedures are allowed.

Apparently you have an AETNA PPO and their PPO network is massive and for them to try to control the order of procedures when they have 10s of thousands of doctors would be nearly impossible. If that was the case, doctors wouldn't be able to treat patients without spending more time on the phone than they do treating patients. Maybe PPOs have changed but that has never occurred for me or my family.

When I was with AETNA and had fatigue, I read that there was a possibility that it could be caused by a sudden drop in blood pressure and a "tilt table" test (an 8 hour procedure) was required to determine if that was happening. I discovered that Stanford hospital did "tile table" tests and made an appointment with a doctor at Stanford hospital (everyone at Stanford hospital was in-network) and after a visit, I requested the "tilt table" test and they set up an appointment.

petitefrancaise

It's done through a third party called Medsolutions.
Changes to policy date back to February 2011, since then all non-urgent MRI/CT + few others require pre-certification.
More details here:
http://www.midlandschoice.com/provid...tnaPreauth.pdf

The patient doesn't do it, the provider (dr) is responsible for getting the approval code.

You will be aware of course, that doctors are really fed up with all the insurance bureaucracy, that they take on extra staff to do all this tedious stuff and then pass on the costs to ...???? guess.

Michael

OK, that explains it. I had an AETNA PPO for about 40 years from 1960s to early 2000 and it was considered the premier provider. There was never problems with coverage, billing, or anything. The only small issue I had was that when I had a procedure done at Stanford hospital, they billed me for out-of-network care for one doctor. When I called and said all doctors at Stanford hospital are in-network, they said I was right and they accidently billed it as out-of-network since the doctor wasn't on their list and immediately changed the bill to in-network.

However Sugarmoona also complained about AETNA recently when her husband had a heart attack so it appears that they aren't as good as they used to be.